Diseases of the Esophagus最新文献

Esophageal cancer ranks among the top 10 most prevalent cancers worldwide, with Denmark experiencing over 800 new cases annually and a five-year survival rate as low as 10%-15%. Despite treatment advancements, prognostic accuracy remains challenging. This study uses the widely adopted Union for International Cancer Control staging system to map esophageal cancer survival across stages. Between January 2013 and December 2021, 7855 esophageal cancers were registered in the Danish Esophagogastric Cancer Group database, covering 99% of all Danish esophageal cancers. Patients were stratified by treatment approach and histological type and staged according to the Union for International Cancer Control tumor-node-metastasis classification. All-cause mortality from diagnosis served as the endpoint, with follow-up until September 12, 2023. Statistical analyses included Kaplan-Meier methods and Cox proportional hazards regression. Definitive chemoradiotherapy showed lower overall survival (OS) compared with surgical treatment (p < 0.001) yet significantly higher than palliative treatment (p < 0.001). Among patients receiving surgical treatment for squamous cell carcinoma (SCC), no significant differences in OS between stages were observed (p = 0.25). As expected, surgically treated patients had better OS than those receiving palliative care, with 5-fluorouracil, leucovorin, oxaliplatin, and docetaxel-treated patients showing a significant survival benefit (p = 0.001). Notably, a highly selected subgroup with Stage IVb disease who underwent surgery demonstrated unexpectedly high OS. Our examination of one of the most elaborate databases yielded a detailed overview of esophageal cancer survival outcomes. By mapping survival stratified by tumour stage and treatment status based on Danish treatment protocols, we hope to aid clinical decision-making for more individualized treatment protocols.

Conduit necrosis (CN) typically requires operative reintervention with resection of the conduit and reconstructive surgery. We describe the outcomes of managing CN both surgically and endoscopically with a focus on conduit salvage. A retrospective, single center, cohort study of a prospectively maintained database was performed. All patients undergoing esophagectomy with gastric conduit reconstruction between 01/2010 and 01/2024 were identified following which all patients with a documented history of anastomotic leak were excluded. Patients with clinically impactful CN were allocated to the study group. The remaining patients who had no immediate conduit related complications were allocated to the control group. The outcomes of various treatment options for CN were described and variables associated with CN identified. Overall, of the 1043 patients that were identified, 37 (3.5%) were allocated to the study group and 850 (81.5%) to the control group. Comparing to control group patients, CN was more common in cervical compared to intrathoracic anastomoses (13/135 vs 20/598, P ≤ 0.001) and among recipients of neoadjuvant chemoradiotherapy (8/112 vs 13/506, P = 0.009). On multivariable analysis, peripheral vascular disease, cervical anastomosis, and chronic obstructive pulmonary disease were independently associated with CN (odds ratio 8.0, 3.2, and 2.5, respectively). In the 397 patients with CN, endoscopic treatment with selfexpanding metal stents (SEMS), debridement and reanastomosis, early conduit replacement, and cervical esophagostomy was used in 14/12/7/4 patients (37.8%/32.4%/18.9%/10.9%). Salvage treatment was successful in 10/14 treated endoscopically with stents (71.4%), 8/12 re-anastomoses (66.7%), 3/7 replaced conduits (42.9%), and 3/4 esophagostomies (75.0%). Overall mortality from CN was 12.8%, with no difference in management approach. In sum, among appropriately selected patients with significant clinically impactful CN post esophagectomy, endoscopic SEMS is an effective means to salvage the conduit.

Chemoprevention of Barrett's esophagus (BE) represents an opportunity to reduce the burden of esophageal adenocarcinoma (EAC). We conducted a systematic review and meta-analysis to evaluate the assumed causal association between proton-pump inhibitors (PPIs), aspirin and statins, and BE progression, and undertook a comprehensive risk of bias (RoB) assessment. The protocol was prospectively registered (PROSPERO ID: CRD42024532338). Sixteen observational studies and one randomized controlled trial were identified. PPIs and statins were associated with a 54% (adjusted OR 0.46; 95% CI 0.25-0.86; P = 0.02) and 47% (adjusted OR 0.53; 95% CI 0.37-0.74; P < 0.001) reduced odds of progression, and aspirin use was not significantly associated (adjusted OR 0.84; 95% CI 0.65-1.08; P = 0.17). Among observational studies, 6 were at critical RoB and 10 were at serious RoB. The only trial included was at low RoB and reported no significant associations for aspirin and PPI comparisons and high-grade dysplasia (HGD)/EAC. The Grading of Recommendations, Assessment, Development and Evaluations certainty of evidence was very low. All observational studies were at serious or critical RoB. Trial evidence was at low RoB and did not demonstrate any significant differences between aspirin and PPI comparisons for the outcome of HGD/EAC. Given the very low certainty of evidence, there is little rationale to recommend these medications for chemoprevention in BE.

Objectives: This study aimed to develop and evaluate a symptom response to treatment questionnaire tailored for patients following oesophago-gastrectomy for cancer. The goal was to create a tool that could reliably assess changes in symptom frequency, severity, and overall improvement in response to post-operative treatments.

Methods: A multidisciplinary team designed the questionnaire based on patient feedback and a prior survey of 362 patients which identified 36 key symptoms after surgery. The questionnaire incorporated validated items from the European Organization for Research and Treatment of Cancer (EORTC) and was registered with EORTC. A total of 24 patients participated in the initial development phase, providing feedback alongside semi-structured interviews. The revised questionnaire was then reviewed by 16 patients in outpatient and endoscopy settings. The utility of the questionnaire was further tested in a cohort of 50 patients treated for delayed gastric conduit emptying (DGCE) post-oesophago-gastrectomy, with follow-up conducted at 2- and 4-weeks post-intervention.

Results: All 24 patients (100%) in the initial development phase found the questionnaire easy to understand, with 83.3% (20/24) preferring Likert scales to assess symptom improvement. In the subsequent review by 16 patients, 93.8% (15/16) found the questionnaire easy or very easy to complete, and 87.5% (14/16) were open to an online version. In the DGCE cohort, 98% of patients (50/51) completed follow-up with 82% (41/50) very happy and 18% (9/50) happy to complete the questionnaire. Clinical utility was demonstrated with improved symptom frequency and severity after endoscopic pyloric dilatation (P < 0.01).

Conclusion: The symptom response to treatment questionnaire shows promise as an effective tool for monitoring post-operative symptoms in oesophago-gastrectomy patients with high patient satisfaction and significant clinical utility.

Background: Zenker's diverticulum (ZD) is a rare outpouching of the pharyngeal mucosa in the upper oesophagus, predominantly affecting elderly patients. Historically, the management for ZD has been surgery, but less invasive endoscopic techniques have also emerged. One technique that has gained traction is Zenker's peroral endoscopic myotomy (Z-POEM), but there remains no clear consensus on the optimal modality. This study aimed to compare the effectiveness and safety of Z-POEM with alternative treatments, including flexible and rigid diverticulotomy.

Methods: A literature search across MEDLINE, Cochrane, and Scopus databases identified comparative studies evaluating ZD treatments, through October 2024. Outcomes included technical and clinical success, reintervention rates, and adverse events. Data were synthesized using a random-effects model, and heterogeneity was assessed with the I2 index. Subgroup analyses were performed for specific comparisons.

Results: Seven studies involving 747 patients met inclusion criteria. Technical success was high for both Z-POEM (97.4%) and alternatives (95.8%). Clinical success significantly favored Z-POEM (odds ratio [OR]: 2.14 [95% confidence interval: 1.42-3.21]). Reintervention rates were not significantly different and adverse event rates were comparable (9.4% for Z-POEM vs. 12.4% for alternatives), with fewer perforations in Z-POEM. Subgroup analysis revealed that Z-POEM maintained comparable technical success, reintervention, and adverse events rates and achieved significantly higher clinical success than flexible (OR: 2.20) and rigid diverticulotomy (OR: 1.98).

Conclusion: Z-POEM demonstrated superior clinical success compared to alternative techniques. However, the low quality of evidence underscores the need for well-designed studies to validate these findings, and guide treatment decisions for ZD.

The contractile integral of the esophagogastric junction (EGJ-CI) is a high-resolution esophageal manometry (HRM) tool designed to assess EGJ barrier function. However, there is scarce data on the best position to measure the EGJ-CI. We aimed to determine the upright and supine EGJ-CI values best associated with abnormal acid exposure time (AET) and compare their diagnostic performance. Our study included patients with typical gastroesophageal reflux disease (GERD) symptoms who underwent esophageal impedance pH monitoring and HRM. The diagnosis of GERD was defined as an AET > 6%. The cutoff points of the EGJ-CI in upright and supine position that better predict the diagnosis of GERD were obtained by receiver operating characteristic curves. The values of the areas under the curve (AUC) were compared. We included 100 consecutive patients. The median age was 52 (range: 41-59) years. Sixty-seven (67%) patients were female. The median AET was 2.40% (range: 0.52-5.60). Twenty-three (23.0%) patients had GERD. The EGJ-CI value in upright position that correlated best with GERD was ≤34.0, with a sensitivity of 95.7%, specificity of 40.3%, and AUC of 0.719. The supine EGJ-CI value was ≤36.0, with a sensitivity of 82.6%, specificity of 40.3%, and AUC of 0.617. The difference between the AUCs was 0.102 (P = 0.038). Our findings suggest that EGJ-CI measurement should be performed in the upright position as it has a higher yield in the detection of GERD. However, studies with a larger sample are needed to corroborate our findings.

Malnutrition is a common complication among patients with esophageal cancer, significantly increasing the risk of postoperative complications and mortality. Multiple studies have shown that immunoenteric nutrition (IEN) can reduce postoperative infectious complications in patients with esophageal cancer. However, its prognostic impact on patients undergoing radical surgery following neoadjuvant therapy remains unclear. This study aimed to compare the prognostic effects of IEN versus standard enteral nutrition (EN) in patients with esophageal squamous cell carcinoma (ESCC) following radical esophageal cancer surgery after neoadjuvant therapy. This retrospective study included 197 patients with ESCC who underwent radical esophagectomy following neoadjuvant therapy between 2016 and 2022. Of these, 133 patients received postoperative standard EN, while 64 patients received IEN. The primary endpoints were overall survival (OS) and progression-free survival (PFS). The secondary endpoints included the incidence of postoperative complications and changes in relevant blood markers before and after surgery. No significant differences were observed in postoperative hospitalization duration or complications between the two groups. Postoperative C-reactive protein and immunoglobulin M levels were significantly lower in the IEN group compared to the EN group (P = 0.018 and 0.042). Kaplan-Meier survival curves were plotted for 1, 2, 3, and 5 years to compare the effects of IEN and EN on OS and PFS. The log-rank test revealed the following survival rates: 90.6% versus 77.2% (1-year PFS, P = 0.023); 95.3% versus 82.7% (1-year OS, P = 0.015); 71.9% versus 56.7% (2-year PFS, P = 0.035); 76.6% versus 62.4% (2-year OS, P = 0.03); 54.6% versus 41.7% (3-year PFS, P = 0.064); 61.4% versus 49.3% (3-year OS, P = 0.08); 39.4% versus 30.7% (5-year PFS, P = 0.093); and 41.5% versus 32.6% (5-year OS, P = 0.104). Univariate and multivariate analyses identified several independent predictors of 2-year PFS and OS. For 2-year PFS, the independent predictors included body mass index (P = 0.005), ypTNM stage (Pathologic TNM-staging after neoadjuvant therapy) (P = 0.045), ypT stage (Pathologic T-staging after neoadjuvant therapy) (P = 0.030), ypN stage (Pathologic N-staging after neoadjuvant therapy) (P = 0.007), tumor differentiation (P = 0.031), and type of EN (P = 0.004). For 2-year OS, the independent predictors were age (P = 0.015), body mass index (P = 0.004), ypTNM stage (P = 0.013), ypT stage (P = 0.010), ypN stage (P = 0.009), tumor differentiation (P = 0.026), and type of EN (P = 0.001). In patients with ESCC undergoing esophagectomy after neoadjuvant therapy, postoperative IEN accelerates the resolution of the inflammatory state and improves short-term survival, though its long-term benefits remain uncertain. Furthermore, IEN does not significantly affect the postoperative hospitalization duration or the incidence of complications.

Background: Capsule sponge testing for Barrett's surveillance is emerging as an innovative technology to aid endoscopic surveillance programs but has yet to be compared to traditional endoscopy in clinical practice. This study aims to establish the impact of the introduction of capsule sponge testing on dysplasia detection rates.

Methods: Over a 5-year period, data were collected for all patients undergoing endoscopy and capsule sponge testing for Barrett's surveillance in a single health board. The 2-year periods pre- and post-implementation of capsule sponge testing were compared to assess dysplasia yield. Patients undergoing surveillance over the 2-year period 1 January 2021 to 31 December 2022 were dichotomized into two groups: capsule sponge test (±subsequent endoscopy) versus endoscopic surveillance only, to compare endoscopic biopsy results.

Results: Barrett's surveillance was performed in 1568 patients between 1 January 2018 and 31 December 2019 (pre-intervention group) versus 1791 patients between 1 January 2021 and 31 December 2022 (implementation group). In the implementation group, 871 patients underwent traditional endoscopy versus 920 patients undergoing capsule sponge testing (with 157 patients [17.1%] proceeding to endoscopy after capsule sponge test). There were no significant differences in the rates of high grade dysplasia (HGD), intramucosal cancer (IMC), or invasive cancer diagnosed between the groups. However, yield of indefinite for dysplasia and low grade dysplasia (LGD) cases was higher in the endoscopic surveillance cohort.

Conclusions: Capsule sponge testing is non-inferior to traditional endoscopic surveillance for detecting HGD, IMC, and cancer. Further follow-up is required to ensure early dysplasia is diagnosed appropriately in those undergoing capsule sponge testing for Barrett's surveillance.